Development and validation of analytical method for identification of new psychoactive substances using linear retention indexes and gas chromatography-mass spectrometry.

New Psychoactive Substances (NPS) are quickly developing to evade legislation, posing unprecedented challenges to public health and law enforcement authorities around the world. The aim of this work was to develop and validate a simple and reliable non-target gas chromatography/mass spectrometry (GC/MS) analytical method based on linear retention indexes for the expeditious identification of NPS without the need of analytical standards. The method was optimized and validated for 22 different drugs covering ten categories: phenethylamines (amphetamine, MDMA, methamphetamine, 25CNBOMe, 2-FA, 5-MAPB), "classic" drugs (cocaine, ephedrine, THC, heroine), synthetic cannabinoids (JWH-081, AM-2201, JWH-210, MAM-2201), piperazines (o-CPP, p-CPP), tryptamines (5-MeO-MiPT), synthetic cathinones (N-ethylpentylone), synthetic opioids (U-47700), aminoindanes (5-IAI), plant-based substances (Salvinorin-A) and "other" (methiopropamine). Three figures of merit (Selectivity, Precision and Robustness) were evaluated with retention index confidence intervals ranging from 0.5 to 20.6 i.u. and relative standard deviations in the range of 0.003% to 0.027% (repeatability) and 0.02% to 0.29% (intermediate precision). A general equation for estimating linear retention index variation as a function of retention time tolerance has been derived. This result in combination with a 2III6-3 fractional factorial design allowed to conclude column polarity to be only statistically relevant factor as compared to gas flow, split ratio, injection temperature, temperature program offset and column brand.

[Solitary metachronous metastasis of the sternum from pancreatic adenocarcinoma]. / Metastasi umica metacrona dello sterno da adenocarcinoma del pancreas.

Sternal metastases from adenocarcinoma of the pancreas are extremely rare, and even more so when solitary. Two years earlier, the patient reported on here, a 67-year-old man with a solitary osteolytic lesion of the sternal manubrium, had undergone a duodeno-cephalopancreatectomy for adenocarcinoma of the pancreas (G2, pY3, pN1) followed by adjuvant radio-chemotherapy. PET/CT scans, in response to the onset of burning pain in the sternal region, revealed a hypermetabolic area only at the level of the manubrium, while MRI showed a bulging manubrium due to the presence of extensive solid pathological tissue towards the right articulations of the ribs. Abnormal tumour markers were: CEA = 12, n.v. 0-4; Ca 15-3 = 512, n.v. 0-51, Ca 19-9 = 8777, n.v. 0-18. A partial sternectomy was performed with en-bloc resection of the hemiclavicles and the anterior tract of the 1st and 2nd ribs bilaterally with a mediastinic lymphadenectomy and repair with a sandwich prosthesis of prolene mesh and methacrylate, protecting the supra-aortic trunks and the anonymous vein with a polytetrafluoroethylene patch. The histological examination revealed secondary adenocarcinoma with 3 mediastinal metastatic lymph nodes. In view of the severe prognosis, a resection with palliative intent was also performed, which, when carried out in specialised centres, presents no contraindications in terms of cost-benefits.

[Iatrogenic hemothorax and unknown spontaneous rupture of the oesophagus, double dramatic disease]. / Emotorace iatrogeno e rottura spontanea misconosciuta dell'esofago, doppio evento drammatico.

Iatrogenic haemothorax is a dramatic event and generally lethal if not treated appropriately and rapidly. Any thoracic co-morbidity increases the risk of death. Spontaneous rupture of the oesophagus is an equally lethal illness if not treated. We report a case of left haemothorax after a thoracic drain for spontaneous pneumothorax with ipsilateral effusion in a 77-year old male. The patient was operated on 6 hours after admission to hospital. We found a laceration of the left common carotid and an unsuspected rupture of the supradiaphragmatic oesophagus. Repair of the lesions in a single session led to no further complications. The patient was discharged in good condition. We know of only one case in the literature with Boerhaave's syndrome not treated surgically, whereas all the other cases had a negative outcome if surgery was not performed promptly. The non-specific symptoms in our case delayed the correct diagnosis of the spontaneous rupture of the oesophagus. The mortality rate is 31% in the literature even when there is an early diagnosis with well performed surgical reapair. A rapid decision as to the best surgical tactics and sending these patients to referral centres specialising in oesophageal disease are the keys to achieving good results.

How to distinguish an active air leak from a pleural space effect.

AIM: We aimed to distinguish a pleural space effect from an active air leak, using a digital chest drain system that provided continuous air flow and pleural pressure checks. METHODS: between March 2010 and October 2011, we employed 144 digital drains for 138 thoracic surgical procedures. RESULTS: We observed 18 (12.5%) active air leaks, among which 4 (2.8%) were prolonged air leaks characterized by high differential pleural pressure due to increased mean expiratory pressure (>1 cm H(2)O; p<0.0001), and 3 (2.1%) late air leaks, all long-lasting (p<0.0001), predicted by pressure curve divergence before the air flow appearance. We also reported 25 (17.4%) pleural space effects characterized by a high differential pleural pressure, but mainly due to a lower mean inspiratory pressure (<20 cm H(2)O; p<0.0001), and especially related to surgical pleurodesis procedures (p<0.0003) and wide lung resections (p<0.0002); there was no increasing pneumothorax after provocative clamping. CONCLUSIONS: A digital chest drain system, ensuring continuous air flow and pleural pressure measurement, could clearly identify a pleural space effect, avoiding the frequent misinterpretation of an active air leak, and allowing safe removal of the chest tube at the right time.

Use of a sealant to prevent prolonged air leaks after lung resection: a prospective randomized study.

BACKGROUND: Pulmonary air leaks are common complications of lung resection and result in prolonged hospital stays and increased costs. The purpose of this study was to investigate whether, compared with standard care, the use of a synthetic polyethylene glycol matrix (CoSeal®) could reduce air leaks detected by means of a digital chest drain system (DigiVent™), in patients undergoing lung resection (sutures and/or staples alone). METHODS: Patients who intraoperatively showed moderate or severe air leaks (evaluated by water submersion tests) were intraoperatively randomized to receive just sutures/staples (control group) or sutures/staples plus CoSeal® (sealant group). Differences among the groups in terms of air leaks, prolonged air leaks, time to chest tube removal, length of hospital stay and related costs were assessed. RESULTS: In total, 216 lung resection patients completed the study. Nineteen patients (18.1%) in the control group and 12 (10.8%) patients in the sealant group experienced postoperative air leaks, while a prolonged air leak was recorded in 11.4% (n=12) of patients in the control group and 2.7% (n=3) of patients in the sealant group. The difference in the incidence of air leaks and prolonged air leaks between the two groups was statistically significant (p=0.0002 and p=0.0013). The mean length of hospital stay was significantly shorter in the sealant group (4 days) than the control group (8 days) (p=0.0001). We also observed lower costs in the sealant group than the control group. CONCLUSION: The use of CoSeal® may decrease the occurrence and severity of postoperative air leaks after lung resection and is associated with shorter hospital stay. TRIAL REGISTRATION: Not registered. The trial was approved by the Institutional Review Board of the IRCCS-CROB Basilicata Regional Cancer Institute, Rionero in Vulture, Italy.

Gold standard for sternectomies and plastic reconstructions after resections for primary or secondary sternal neoplasms.

BACKGROUND: Between January 1980 and December 1999, 88 patients underwent the surgical resection of sternal tumors: 30 primary malignant tumors, 28 local relapses or metastases from breast carcinomas, 16 other types of tumor, and 14 radionecroses. METHODS: The sternectomies were total in 8 cases, subtotal in 32, and partial in 48. Prosthetic materials covered by flaps of myocutaneous or muscle tissue were used in 55 patients, prosthetic material alone in 13, myocutaneous or muscle flaps alone in 5, and other techniques in the remaining 15. The resection was radical in 78 cases and palliative in the other 10. RESULTS: Forty-eight of the subjects who underwent radical surgery were alive and disease free at the end of the follow-up period. The expected 10-year survival of the patients treated for primary tumors is approximately 85% (Kaplan-Meier), and that of the patients with relapsing breast carcinomas is the same as after 5 years (41.8%). CONCLUSIONS: In our experience, the treatment of neoplasms by means of a broad sternal resection followed by a reconstruction based on the use of prosthetic materials is an effective and safe solution that considerably improves the quality of life and makes it possible to perform curative broad radical resections in the case of primary sternal resections.